After Atkins

Original Content, The Washington Post

A new client shared a familiar story with me: This man, who has struggled with his weight for years, went on the Atkins low-carbohydrate diet, and the pounds seemed to melt away. But after a few months, they started to creep back on. Another woman on Atkins lost only part of her desired weight and then hit a plateau. Still others find that after success with Atkins, their cholesterol levels soar, a potential danger to their health. They all came to me fearful that going off the Atkins diet would mean gaining their weight back. But they knew they had to figure out a different way to achieve their goals permanently.

Their fears are well-founded and point to a central dilemma in weight loss: While losing weight is exhilarating and energizing, it also can be fleeting.

“Unless people transition, they’re going to fail, because the Atkins diet produces weight loss but not weight maintenance,” says James Hill, director of the Center for Human Nutrition at the University of Colorado in Denver. “If people lose weight with the Atkins diet, they need to consider their weight loss as Phase 1 and be prepared to keep it off differently, which would be Phase 2.” Hill was co-author of the Atkins diet study published in the New England Journal of Medicine last year. It found that those in the Atkins diet group had a greater weight loss after three and after six months compared with those on a low-calorie, low-fat diet. After one year, though, there was no difference between the two diet groups.

But weight regain is not a problem unique to the Atkins diet. The struggle has been going on for as long as people have been looking for quick-fix, formulaic diets. In the 1970s, people lost weight by cutting carbohydrates with Atkins or Scarsdale. The ’80s brought us high-protein, modified fasts (remember Oprah and Optifast?). In the ’90s, low-fat diets were the rage. Now we’ve come full circle with low-carb diets. All these diets work because they dramatically lower your calorie intake. But the challenge is the same no matter what diet you follow: At some point, you must transition from the diet to a healthy, everyday eating plan that will maintain your weight and enhance your health.

In 1994, Hill and others founded the National Weight Control Registry to study the characteristics of people who successfully maintain their weight losses (known as “maintainers”). People in the registry have lost an average of about 70 pounds and have kept it off for an average of seven years.

The registry and other studies have found many factors that separate successful weight-loss maintainers from unsuccessful regainers:

• Diet: The registry found maintainers eat a low-fat diet with 24 percent of their calories coming from fat, 19 percent from protein and 56 percent from carbohydrates (much of it low-calorie, complex carbohydrates). Only 1 percent eat a low-carbohydrate diet (with less than 24 percent of their calories from carbohydrates).

The registry and other studies have found that maintainers eat more vegetables and fewer calorie-dense foods, such as fried food, fats, fatty meats and sweets, and they often substitute low-fat for high-fat foods.

Maintainers reduce portion sizes, reduce frequency of snacking, and they eat foods such as cheese, butter, high-fat snacks, fried foods and desserts less than once a week. They become satisfied with smaller portions and are less attracted to sweet or fatty foods.

Regainers increase their fat intake while maintainers keep it consistently low. But maintainers don’t completely deny themselves. They changed their basic food patterns, but they allowed themselves fewer but more meaningful indulgences. Regainers, on the other hand, went on very restrictive diets not permitting themselves any room for favorite foods. They felt deprived and easily fell back into old patterns.

• Eating style: The registry found successful maintainers prepare and eat the majority of their food at home, dining out about once a week, which is less often than the general population. The registry and another study found maintainers are more likely to eat five times a day, while regainers are more likely to skip meals, snacking on candies and chocolates more often. The registry found that a strikingly high number of maintainers eat breakfast.

• Self-monitoring: The registry reported that 75 percent of maintainers weigh themselves at least weekly or daily. This helps them nip any minor weight gains in the bud. On the other hand, regainers either accept larger weight gains or don’t notice their weight creeping up until they gain a large amount. One study found that successful maintainers develop a “healthy narcissism” about their appearance and physical condition. The registry and numerous studies have found that maintainers monitor their eating by occasionally keeping food diaries to increase awareness.

• Physical activity: Nine out of ten of the registry participants engage in regular physical activity. “During weight loss, diet is the driver. But during weight maintenance, physical activity becomes the key,” says Hill, whose new book, “The Step Diet” (Workman, 2004), incorporates elements from registry findings.

• Coping skills: Most people have comparable levels of stress and unpredictability in their lives, but some are able to handle it more effectively than others. Maintainers are more likely to face their problems, while regainers react emotionally or avoid problems by sleeping, drinking or eating. Maintainers are also more likely to seek support from friends, family and professionals.

• Lifestyle: Many maintain weight loss only upon making major lifestyle adjustments. One study found when home-bound women became more involved in activities outside of their homes, they were more likely to maintain weight loss. They became more confident and took responsibility for their lives and their size. The activities you choose to engage in and the people you spend time with influence weight-maintenance success. Often this means making new, healthier friends and including spouses in your lifestyle changes. Spousal support is necessary for long-term success, even if it may not be necessary short term.

• Goals and expectations: Maintainers are more likely to be patient, setting small, reachable goals. They accept dietary change as part of their lives rather than as part of a temporary diet. They realize they need to be continually conscious of their food and activity levels and work at staying in shape.

The evidence is clear: The battle of the bulge is won at the margins. Sweeping dietary overhauls are impractical and don’t work over time. Shrewd, small, concrete changes that can be easily incorporated into your daily routine lead to success.

Katherine Tallmadge is a Washington nutritionist and author of “Diet Simple” (Lifeline Press, 2004). Send e-mails to her at food@washpost.com.

© 2004 The Washington Post Company

Have Your Fill: How to Eat Just the Right Amount for You

It’s not rocket science: Eat fewer calories than you burn and you’ll lose weight.

But somehow it seems almost impossible to do. How could something so simple be so hard? The dilemma we all face is how to eat less without feeling hungy and deprived. The solution, while not as important for short-term weight loss, is essential to weight maintenance. Any diet that keeps us hungry is doomed to fail over the long haul.

For decades, scientists have been digging for clues about what influences the decisions to start and stop eating. They have found that our bodies have a complex physiological signaling system that tells us when we’re hungry and when we’ve had enough. When you’re eating, nerves in the stomach wall detect your stomach is stretching. They send satiation messages to the brain and you start to feel full. When food is sensed in the intestines, several substances are activated there as well, including nerve regulators and hormones such as cholecystokinin (CCK).

The physiological sensation of hunger has been more difficult for researchers to pin down. Emerging research points to ghrelin (pronounced GRELL-in), a hormone sent into your bloodstream by the stomach when it is empty.

The level of ghrelin “goes up before meals — making you hungry — while the other satiating hormones go up after eating [with ghrelin going down], causing you to stop,” says David E. Cummings, associate professor of medicine at the University of Washington and the Veterans Affairs Puget Sound Health Care System. “With these two systems, you have physiological control over pre-meal hunger and post-meal satiety.”

Of course, we’re not automatons governed strictly by physiology. The decision to eat is also governed by things we can control.

“In humans, ghrelin may not be the only driver. Initiation of meals is a complex process that deals with social cues, smells, sights and more,” says Phil Smith, co-director of the Office of Obesity Research at the National Institute of Diabetes & Digestive & Kidney Diseases.

Evidence suggests that many factors are related to your satisfaction with a meal and ultimately, your ability to lose and maintain weight:

Portion Size

In a series of widely known experiments over the past five years, researchers found that the amount of food you are served will affect how full you feel and how much you eat. In the studies, people were given varying amounts of macaroni and cheese, submarine sandwiches and bags of popcorn or chips. In each case, when they were served smaller portions, they ate those portions and felt satisfied. But when they were given larger portions, without realizing it, the subjects (including children, in other similar studies) ate significantly more — sometimes 50 percent more. 

This effect persisted. Over two days, when portions were 50 percent larger at each meal, subjects ate 16 percent more (328 extra calories in women and 522 extra calories in men per day). When the portionswere 100 percent larger, subjects ate 26 percent more (531 extra calories in women and 806 extra calories in men).

Those extra calories, added daily over the course of a year, would pack 50 pounds more on women and 80 pounds more on men.

“This is a case where physiological satiety cues are overridden by environmental cues such as large portions and the easy availability of food,” says Barbara Rolls, co-author of the studies and a professor of nutritional sciences at Pennsylvania State University in University Park. “When served larger portions, people adjust their level of satiety to accommodate greater calorie intakes.”

Fortunately, studies also have found that the reverse is true. When good-tasting, lower-calorie foods or portion-controlled meals are available, people will eat those and feel just as satisfied. In fact, studies of successful weight loss maintainers find they easily adjust to smaller, more appropriate portions of higher-calorie foods.

An interesting study showed that preschool-age girls who regularly overeat can be taught how to change their behavior by learning to pay attention to their natural hunger and satiety signals.

Water and Air Content

Barbara Rolls, Professor and Director of the Laboratory for the Study of Human Ingestive Behavior, and colleagues, found that as long as the volume of the food is high, people can feel full with fewer calories. 

In one study, participants who drank milkshakes blended with more air, compared with the same shakes containing less air, ate 12 percent less at the next meal without realizing it.

In another experiment testing this phenomenon, Rolls served subjects one of three meals. They were served either Chicken & Rice Casserole, Chicken & Rice Casserole with a glass of water, or Chicken & Rice Casserole with water added, making it into a soup. Only in the condition where the subjects ate the soup, did thy feel full, while eating 25% fewer calories.

Next, the researchers served salads of various sizes and calorie levels before a main course to determine the effect on the calorie intake of the whole meal. Participants consumed the fewest overall calories — 100 calories fewer — when they were served the largest salad before a meal.

How Does This Work?

Researchers surmise that a large food volume caused by water or air, even without added calories, influences satiety in at least three ways:

-It causes stomach stretching and slows stomach emptying, stimulating the nerves and hormones that tell you when it’s time to put down the fork,

-Seeing a large volume of food can increase your ability to feel satisfied by it, and

-Finally, the larger a meal is and the longer a meal goes on, studies show, your satisfaction declines and you lose interest in completing it

Pump It Up

Get back to basics and listen to your body signals. Start by rating your hunger on a five-point scale:

0 = ravenous

1 = hungry

2 = could eat, could wait 

3 = satisfied, no longer hungry 

4 = uncomfortably full

5 = stuffed

Give yourself a rating before you start eating and another rating when you finish. You should eat when you’re hungry (1) and stop when you’re no longer hungry (3)*

To feel full with fewer calories, try these tips from Barbara Rolls, author of “Volumetrics,” whose research shows that people have greater success with weight loss when they eat larger servings of foods that have a high water content, such as cooked grains, vegetables, fruits, soups and stews:

• To lower the calories and increase the portion size of a favorite recipe, pump up the volume by adding vegetables as often as you can. This way, you can eat your usual portion for fewer calories

• Choose fresh fruits over dried fruits or juices. For 100 calories, you could eat 1/4 cup of raisins or two cups of grapes. (You’re more likely to fill up on the grapes.)

• Whip air into your yogurt and fruit snack by putting it into a blender and turning it into a smoothie.

• Try air-popped popcorn (3 cups is only 90 calories) or flaky or puffed cereals.

• Start lunch or dinner with a bowl of broth-based vegetable soup or a big vegetable salad with low-calorie dressing.

• Turn main courses into soups or salads by adding water or vegetables.

— Katherine Tallmadge

© 2004 The Washington Post Company